Numbers that Count: How important is your system's annual total of IV starts?

Gary Ludwig, MS, EMT-P

Monday, January 5, 2009
Gary Ludwig, MS, EMT-P

During the Vietnam War, updated body counts were reported on the evening news, almost as commonplace as baseball scores. The idea was that the higher the number of communists we killed, the more successful people would think we were. In retrospect, this concept of counting bodies was a measurement without value.„

But it_s common to focus on an obvious scale of success or failure, during war or in civilian life. In EMS, we often follow the same senseless approach and count unimportant areas of our performance.„

Take the case of the EMS manager who proudly displays graphs of how many times their service started IVs in the past year. The visuals look pretty, and the manager can brag about a 95% IV success rate. Big deal! What does the number really tell you about the operation? You don_t know how many times they stuck the patient to get that IV, how long it took them, if they used standard precautions, if they used the right fluid or if they administered any drugs through it.

What about intubations? Let_s say your system had a 99% success rate of intubating patients. Looks good, but did you measure whether the paramedic used the appropriately sized tube or how long it took them to get a patient intubated? If the average was greater than 10 minutes, and in the majority of intubations it took two or three tries before the paramedic was successful, isn_t that data important?

Response times might be the trickiest performance component to measure because there_s no standard on when to start and stop the response clock. Isn_t it important to analyze all response times based on a customer-focused perspective, such as starting the clock when the call is answered versus when the wheels are rolling?„ Also, how important is it to measure our response time to certain medical calls, such as a chief complaint of flu-like symptoms?

Why We MeasureTypically, we think we_re measuring performance in order to determine compliance levels in our EMS system. But many states also require a quality improvement (QI) program as a condition of operating a license to transport patients. What the majority of those state laws or regulations don_t say is how to actually run a QI program.„

Too often, I hear about services that operate a QI program under the principle of the "Gotcha Police." These programs review patient care documents and data, looking for acts of omission (e.g., someone who failed to provide oxygen when it was indicated) or commission (e.g., restraining a patient who didn_t need it). They look for behavior that qualifies as a protocol infraction, which may lead to investigations and potential disciplinary action.„

In these types of organizations, absenteeism and turnover are often high and morale low. Employees walk on eggshells, waiting for the hatchet to drop on their neck. This is no way to run an EMS agency.

QI programs should aim to reveal and resolve system problems; a secondary goal is to identify employees who need skill enhancement to provide better patient care. QI should never be about disciplining an employee.

Begin with the EndQI programs usually focus on important performance factors with known values at the lower end of the scale and then define what the acceptable rate should be. But should we be looking at things differently?„

Stephen Covey_s book,„The Seven Habits of Highly Effective People, stresses that we should "Begin with the end in mind." Covey_s point is that we should start a process by identifying the ultimate goal and going backward in our attempt to obtain it.„

If our ultimate goal is to provide good customer service to our patients, shouldn_t we be measuring the satisfaction of the customer? If our IV success rate is 95% but we stick a patient four or five times before the IV is started, have we really achieved success in the mind of our patient, aka the customer? And have we successfully made the patient better off than when we found them?

To have an exceptional QI program, start by assessing how you_re measuring performance. Identify your goals, and ensure your measurements relate to those goals, and then you can set a path for continuous performance improvement.„JEMS

Gary Ludwig, MS, EMT-P, is a deputy fire chief with the Memphis (Tenn.) Fire Department. He has 30 years of fire and rescue experience. He_s chair of the EMS Section for the International Association of Fire Chiefs and can be reached at„www.garyludwig.com.

Learn more from Gary Ludwig at the EMS Today Conference & Expo, March 2Ï6 in Baltimore.